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Based on record review and interview, the hospital failed to ensure that a verbal and written grievance from patient #1 was thoroughly investigated. Findings:

On 09/22/2010 at 10:00am interview with S8 LCSW Supervisor, revealed that she was aware of a verbal complaint/grievance voiced by patient #1 on 05/17/2010. Further interview with S8 revealed that she was notified by S4 RN Nurse Manager that patient #1 wanted to verbalize concerns surrounding poor care and services on the psychiatric unit. Further interview revealed that S1 Patient Advocate, S4 RN, and Dr. S10 Psychiatrist and patient #1 were present and discussed issues which ranged from Dr. S14 being rude to direct staff being unprofessional and rude. Further interview at this time revealed that S1 Patient Advocate and/or staff S4 RN obtained and entered the complaint data for patient #1 prior to discharge.

On 09/22/2010 at 2:20pm, interview with S4 RN Nurse Manager, revealed that she was aware aware of a verbal complaint voiced by patient #1 prior to time of discharge. Further interview with staff S4 revealed that she considered patient #1's complaint as a concern and not as a grievance.

Further interview at this time revealed that no investigation was completed regarding patient #1 concerns that direct care workers were rude and unprofessional, or other issues the patient verbalized. Further interview with S4 RN confirmed that she did receive a written letter from S1 Patient Advocate on 06/17/2010 regarding the concerns of patient #1. S4 acknowledged that patient #1 also sent the hospital a letter concerning various complaints and concerns during her hospitalization from 05/13/2010 to 05/18/2010. Further interview with S4 revealed that she did not conduct an investigation regarding the allegations of poor patient care and services addressed by patient #1.

Review of the letter dated 06/24/2010 from the hospital in response to the written grievance filed by patient #1 revealed that "Since the receipt of your complaint, a detailed investigation has been conducted by several administrative and supervisory personnel." Continued review of the letter addressed to patient #1 revealed that "interviews with the medical team that treated you were held and the six concerns you listed were discussed at length." Additionally, the letter indicated that "I can assure you that admission procedures in the APU (acute psychiatric unit) have been revised to include more specific explanations, partly due to your comments."

Based on record review and interview, the hospital failed to ensure that all least restrictive measures were implemented prior to the administration of an antipsychotic medication used as a chemical restraint for patient #1. Findings:

Review of the record for patient #1 revealed an admission date to the facility on 05/13/2010 at 4:00pm. Further review of the record revealed that the admitting Axis I diagnosis was Bipolar I, manic, moderate; Axis II was deferred; Axis III- Hepatitis C; Axis V- Global assessment functioning- 30-35. Further review revealed that the following medications were ordered at time of admission: Lithium 300mg, 1 tablet three times daily, Seroquel XR 100mg, 1 tablet at bedtime. Further review revealed that in addition to these medications, the following medications were ordered PRN (as needed). Geodon 20mg IM, every 12 hours PRN agitation and Ativan 2mg IM, every 6 hours PRN agitation.

Review of the nursing progress note at the time of admission on 05/13/2010 at 1600 (4:00 PM) revealed that patient #1 was admitted ambulatory to the Acute Psychiatric Unit on an order of PEC (physician emergency certificate). Further review of the nurses' admission note revealed that patient #1's affect was bland, preoccupied at times, cooperative with staff. The nurse noted elopement precautions and close observation was initiated for the patient. Further review revealed that no behavior problems were observed and the nursing assessment was completed. Review of the risk assessment completed by the RN at time of admission revealed that patient #1 did not demonstrate pacing, agitation, increased anxiety or a rapid change in behavior.

Review of the psychiatric nursing admission assessment completed by the RN on 05/13/2010 at 1715 (5:15 PM) revealed that patient #1 did not exhibit hallucinations, delusions, but she was oriented to person, place, and time. Further review of the RN assessment revealed that the patient's general demeanor (affect/mood) was not completed by staff.

Review of the behavioral therapeutic surveillance flowsheet revealed every 15 minute checks for 05/13/2010 beginning at 1700 (5:00 PM) to 1915 (7:15 PM) and that patient #1 was in the group room. Further review of the every 15 minute checks revealed that the patient was quiet, with no documented behaviors noted.

Review of the nurses progress notes dated 05/13/2010 at 1902 (7:02 PM) by S11 revealed patient #1 was crying loudly in the dayroom with visitors present. Continued review of the nursing progress notes by S11 revealed that "patient (#1) was acting hysterical" and at 1912 (7:12 PM) S11 noted that patient #1 was "refusing to redirect; patient crying loudly, disturbing other patients and visitors". According to documentation by S11 LPN, on 05/13/2010 at 1925 (7:25 PM) "patient given Geodon 20mg IM (antipsychotic) and Ativan 2mg IM (antianxiety) as directed by physician for anxiety and aggression" (according to admission orders). Review of the next progress note entry by S11 on 05/13/2010 at 2120 (9:20 PM) revealed "patient resting quietly in bed. Will continue to monitor."

Further review of the medical record revealed that the RN did not assess patient #1 prior to, or after administration the the antipsychotic and antianxiety PRN medications. Documentation did not support that staff offered or attempted least restrictive measures before administering the antipsychotic to patient #1.

On 09/22/2010 at 2:00pm, interview with S4 RN Nurse Manager/Program Director confirmed that an RN must assess a patient prior to administering a PRN medication. S4 confirmed that staff must attempt and document that least restrictive measures were attempted prior to the administration of the PRN injections. S4 also confirmed that the RN did not document an assessment on patient #1 prior to the administration of the antipsychotic medication. Further interview with S4 confirmed that the RN did not document that least restrictive measures were attempted prior to the administration of the PRN medication.

Based on record review and interview, the hospital failed to ensure that a registered nurse evaluated the nursing care for each patient as evidenced by the RN's failure to assess and ensure that least restrictive measures were attempted prior to patient #1 receiving a PRN (as needed) antipsychotic and PRN antianxiety medications. Findings:

Review of the medical record for patient #1 revealed an admission date to the acute psychiatric unit on 5/13/2010 at 4:00 PM. Further review of the record revealed an admitting diagnosis of Bipolar and that the admitting physician ordered Lithium 300mg three times daily, Seroquel XR 100mg, at bedtime. Further review revealed that in addition to these medications, the following medications were ordered PRN (as needed). Geodon 20mg IM, every 12 hours PRN agitation and Ativan 2mg IM, every 6 hours PRN agitation.

Review of the nursing progress note at the time of admission on 05/13/2010 at 1600 (4:00 PM) revealed that patient #1 was admitted ambulatory to the Acute Psychiatric Unit on an order of PEC (physician emergency certificate). Further review of the nurses' admission note revealed that patient #1's affect was bland, preoccupied at times, cooperative with staff. The nurse noted elopement precautions and close observation was initiated for the patient. Further review revealed that no behavior problems were observed and the nursing assessment was completed. Review of the risk assessment completed by the RN at time of admission revealed that patient #1 did not demonstrate pacing, agitation, increased anxiety or a rapid change in behavior.

Review of the psychiatric nursing admission assessment completed by the RN on 05/13/2010 at 1715 (5:15 PM) revealed that patient #1 did not exhibit hallucinations, delusions, but she was oriented to person, place, and time. Further review of the RN assessment revealed that the patient's general demeanor (affect/mood) was not completed by staff.

Review of the behavioral therapeutic surveillance flowsheet revealed every 15 minute checks for 05/13/2010 beginning at 1700 (5:00 PM) to 1915 (7:15 PM) and that patient #1 was in the group room. Further review of the every 15 minute checks revealed that the patient was quiet, with no documented behaviors noted.

Review of the nurses progress notes dated 05/13/2010 at 1902 (7:02 PM) by S11 revealed patient #1 was crying loudly in the dayroom with visitors present. Continued review of the nursing progress notes by S11 revealed that "patient (#1) was acting hysterical" and at 1912 (7:12 PM) S11 noted that patient #1 was "refusing to redirect; patient crying loudly, disturbing other patients and visitors". According to documentation by S11 LPN, on 05/13/2010 at 1925 (7:25 PM) "patient given Geodon 20mg IM (antipsychotic) and Ativan 2mg IM (antianxiety) as directed by physician for anxiety and aggression" (according to admission orders). Review of the next progress note entry by S11 on 05/13/2010 at 2120 (9:20 PM) revealed "patient resting quietly in bed. Will continue to monitor."

Further review of the medical record revealed that the RN did not assess patient #1 prior to, or after administration the the antipsychotic and antianxiety PRN medications. Documentation did not support that staff offered or attempted least restrictive measures before administering the antipsychotic to patient #1.

On 09/22/2010 at 2:00pm, interview with S4 RN Nurse Manager/Program Director confirmed that an RN must assess a patient prior to administering a PRN medication. S4 confirmed that staff must attempt and document that least restrictive measures were attempted prior to the administration of the PRN injections. S4 also confirmed that the RN did not document an assessment on patient #1 prior to the administration of the antipsychotic medication. Further interview with S4 confirmed that the RN did not document that least restrictive measures were attempted prior to the administration of the PRN medication.

Based on observations and interview, the hospital failed to ensure that patients on the psychiatric unit have enough space to participate in group therapy and eat meals at a table. The total census on the 26 bed facility was 26 on all days of the survey and patients were observed eating their meals and holding their meal trays in their laps because there was not enough chairs for all patients to eat at the tables available to patients at meal time. Findings:

On 09/20/2010 at 10:00am observation of the group room on the psychiatric unit revealed there were 26 patients and 3 staff present. Further observation revealed that the room appeared crowded and did not provide a comfortably all patients that were present.

On 09/20/2010 at 10:26am, observation of the group room on the psychiatric unit revealed 25 and 3 staff were in the room. Further observation at this time revealed that staff were conducting a recreational therapy group and that 14 patients were sitting away from group and were not participating.

On 09/20/2010 at 11:22am, observation of the group room revealed 22 patients present. Further observation revealed that 15 patients formed a circle and participated in group, but 7 patients were sitting away from group and were not encouraged to participate.

On 09/20/2010 at 11:55am observation of the group room revealed that it was also utilized as a dining room and that there was only 19 patient chairs available for the 4 portable tables. Further observation revealed that 14 patients ate at tables and 12 patients had to hold their trays on their lap to eat because chairs were not available to sit at the table.

On 09/20/2010 at 12:00pm, interview with S6, MHT (mental health technician) Supervisor, confirmed that not all patients can be served meals at tables at the same time due to lack of chairs and table space. Further interview with S6 confirmed that this was the only room on the unit utilized by patients for both group therapy and meals.

On 09/27/2010 at 12:30pm, interview with staff S15 DON confirmed that the total square feet space in the group/dining room on the unit was 580 square feet. Further interview revealed that this room is only room on the unit currently being utilized for groups/dining. The DON further confirmed that there are not enough chairs available to accommodate all patients during meals and therapies. This area reveals approximately 22.3 square feet per patient.